____ Adjunct Faculty

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					Affidavit of Pension
____ Adjunct Faculty Full Time Faculty Semester: Fall ____ Spring ____ Year _____

Please complete and return this Affidavit with your signed contract. 1) Are you or have you ever been a member of the following State of New Jersey administered retirement systems? No dates  Public Employees Retirement System ____________________  Teachers Pensions and Annuity Fund ____________________  Police and Fireman’s Retirement System ____________________  Alternate Benefit Program ____________________ If you did participate in any of the above retirement systems, did you withdraw your funds or retire from the system?  No  Withdrew Funds  Retired - ________________
Retirement Date

Yes-please check the corresponding system and include participation

2) Do you own an active annuity contract that contains employee and employer contributions based upon higher education employment? No  Yes ______________________________________ Educational System ______________________________________ Investment Company Employee Signature _____________________________________________ Please Print Name _______________________________________________ Social Security Number ______________ Department _____________________ Date _____________________________

**This form must be completed each semester*